Experiences of dyslexia in GP training in the UK: a qualitative study

There is a lack of awareness

Dyslexia was often diagnosed late, owing to poor awareness and masking. Educators highlighted a noticeable rise in diagnosis within IMGs, perceived to be following an increase in IMG residents and lack of screening in their primary medical qualification universities. Furthermore, some educators wondered ‘whether there’s a second language dyslexia sort of thing’ (P21).

While participants did feel that awareness was improving, knowledge regarding its features and adaptive strategies, was lacking:

‘There’s a lot of feeling that it’s all to do with spelling and that’s not necessarily a full representation.’ (P3)

Stigma can feature with dyslexia

While people were ‘moving away’ (P2) from stigma, it still featured, particularly among IMGs: ‘There’s a stigma. When I referred the overseas trainee there was lots of hesitation’ (P14).

Several participants disclosed their diagnosis to access support; some even comfortably informed patients. Nonetheless, others expressed reluctance:

‘If I was to tell them that I had dyslexia, it would mean I'm not as quick. I'm not as good. I just didn't feel comfortable saying that.’ (P6)

Both positive and negative attitudes have been reported

Participants reported negative attitudes from colleagues and supervisors including accusations of being unfairly ‘facilitated for no reason’ (P12), discrimination, and lack of support:

‘Trainers are just not engaged or very blasé towards dyslexia.’ (P11)

Nonetheless, positive attitudes were also reported from colleagues and educators, including professional support and wellbeing (PSW), where provision of coaching was helpful. Educators expressed willingness to learn and adapt to the needs of dyslexic residents, with close relationships formed: ‘You end up more bonded when you've had to work harder to get people through’ (P22).

Dyslexia can cause both relief and psychological burden

Psychological burden was high among dyslexic GPs and residents, including burnout, stress, and depression:

‘There’s a risk of burnout during training and post-training. I've probably burnt out three, four times.’ (P1)

Following diagnosis, participants described a ‘grief process’ (P5), although others described ‘relief’ (P3), as it explained their struggles. Some made positive adjustments following diagnosis: ‘I started to relax, became more self-aware and nicer to myself’ (P11).

General practice appeals to dyslexic doctors

Participants often selected general practice as a career owing to its emphasis on interpersonal skills: ‘GP is a natural specialty because we spend a lot of time talking and listening’ (P3).

Nonetheless, some doctors did choose general practice owing to its shorter training programme and as an alternative choice to hospital medicine:

‘Surgery is a really practical role and I’m quite practically minded. But I think training is just too long.’ (P6)

Training may not fully prepare dyslexic doctors

Participants commented that 3 years of GP training could be insufficient for dyslexic doctors as training did not necessarily reflect working life post-CCT. During training, the focus was primarily on assessments and time after completion of exams was valuable to learn the ‘role of a GP’ (P21). Several participants found training extensions useful:

‘I had extended training so by the time I got out, I felt more confident. I don't know how someone with three years of training who is dyslexic can work as a GP.’ (P4)

Furthermore, working full-time could be challenging, with less-than-full-time an option: ‘I went to 60% less-than-full-time because it was getting overwhelming’ (P12).

Moreover, reasonable adjustments during training did not always follow post-CCT:

‘GP partners would struggle employing somebody with dyslexia. Potentially you'd have to give more time for admin. Potentially less appointments.’ (P22)

This was perceived to be related to NHS workforce pressures that were heightened post-CCT:

‘Realistically, in the current climate and with most practices struggling, they probably won't be able to give that flexibility.’ (P10)

Nonetheless, educators emphasised that approaching a familiar practice was helpful, in addition to negotiation. However, while some dyslexic GPs successfully negotiated adjustments, this was not always possible:

‘That hasn't been something that I've successfully been able to negotiate post-training. It’s been, well you can have catch-up slots, but we don't think it’s fair if you have longer appointment times and fewer appointments.’ (P3)

Dyslexic GPs may pursue portfolio careers

Dyslexic GPs could pursue portfolio careers, with locum being one option. Another possibility was working in other clinical environments, such as urgent care or other specialties (for example, emergency medicine, occupational medicine). Other options were non-clinical roles: ‘Some go into research and training. Some have gone into a purely academic side’ (P14).

Non-clinical administration is challenging

Completing non-clinical administration post-CCT was burdensome, including invoices, taxation, and pension forms. Seeking help from accountants was important. Completing annual appraisal and revalidation were difficult, with comparisons drawn to training: ‘I still carry it post-CCT for my appraisal portfolio. I struggle with that’ (P10).

Written examinations can be challenging

Participants found written examinations (for example, AKT) difficult with dyslexia, related to issues with ‘reading time, comprehension, and the focus of attention for long periods of time’ (P1). Moreover, screen-reading could be demanding, in addition to interpretation of some question-stem wording. Several dyslexic participants failed AKT; additional exam time was effective, albeit exhausting.

Practical examinations are perceived to be easier

Some participants found practical assessments easier, owing to the focus being on consultation skills: ‘I would outperform in OSCEs [objective structured clinical examinations] but underperform in MCQs [multiple choice questions]’ (P10).

Nonetheless, some participants reported failure (for example, SCA, recorded consultation assessment [RCA]), related to difficulties with reading time, poor verbal expression, reduced interpersonal skills, and time-keeping under pressure. Reasonable adjustments included additional reading time and increased duration of consultations.

Workplace-based assessments (WPBAs) can be difficult

Dyslexic residents experienced difficulties with WPBAs. Educators predominantly emphasised issues with dyslexic residents’ portfolio engagement:

‘They avoid learning logs, and suddenly they're under pressure before an ESR [educational supervisor report]. They'll put loads of log entries on, generally not brilliant quality.’ (P10)

Some educators noted that disorganisation was compounded in IMGs who were ‘completely new to NHS and hit with this IT platform’ (P26).

Learning log reflections were onerous, owing to challenges with composition and grammar:

‘I found the portfolio an absolute drain on my life. The learning logs. Oh God, I used to find it so difficult to put things into words.’ (P3)

Some felt that the portfolio should allow oral entries, while others used artificial intelligence and voice recognition to write reflections:

‘I would audio-note myself. But if I typed, there would be spelling errors everywhere and it wasn't succinct.’ (P6)

Some commented that WPBAs requiring organisational efficiency, particularly audits, quality improvement activities, and prescribing assessments were difficult, although others disagreed. Furthermore, for WPBAs involving feedback from supervisors, colleagues, and patients, negative comments occurred, related to residents’ organisation and time-keeping. Other WPBAs, such as case-based discussions, were perceived to be less challenging as others ‘would do most of the writing’ (P3).

Interactive learning is effective

Interactive methodologies were effective for dyslexia, including reading guidelines while seeing patients, note-taking, and annotation. Audiovisual learning was effective, including audio-notes, pictures, tables, podcasts, mind-mapping, mnemonics, and gamification. Study groups, verbal explanations, the Pomodoro technique and question banks were also effective.

Educators emphasised their role. Reviewing mock questions with residents to check clinical reasoning and observing their consultations were valuable. Exam techniques included the cover test, dissecting the question, reviewing question formats and visualisation. Practising time management was important.

Experiences of dyslexia and its strengths are unique to every individual

Participants expounded workplace adjustments to improve processing and time-keeping. Nonetheless, they emphasised that interventions were individualised:

‘One of the dangers with something like dyslexia is saying there is just one way to deal with this because I don't think it’s that homogeneous.’ (P11)

Participants detailed strengths, including enhanced interpersonal skills, creativity, and lateral thinking: ‘It gives you that ability to connect with people. That’s given me an advantage and is actually an asset to my job’ (P3).

However, one participant did not feel that dyslexia gave strengths beyond their peers, while another commented that enhanced skills could be diminished by additional burden.

Adjustments to GP clinics are helpful

Longer individual appointment times, catch-up slots, and breaks helped improve time-management during clinics:

‘I have three catch up slots throughout the morning ... My morning finishes later.’ (P3)

Nonetheless, some commented on the impracticality of lengthy appointment durations for residents: ‘I don't know how much more time we can give. We already give 45 minutes per consultation’ (P25).

Longer clinics could also be detrimental, including reduced administration time, difficulties undertaking home visits, and being exhausting:

‘By increasing to 15 minutes for the same amount of patients, it means that I'm constantly consulting for 8 hours straight and mentally I can't do that.’ (P6)

A further measure was ensuring familiarity, through adequate induction, and maintaining the same clinic room, although this was sometimes unfeasible: ‘It’s got merit in a large organisation, but in a smaller practice you might not have a dedicated room’ (P22).

Managing patients with complex or multiple issues was challenging and keeping to one issue per appointment could be helpful. Furthermore, documenting information immediately during consultations, could improve time-keeping.

Participants commented on the importance of incorporating adequate supervision for dyslexic residents, with flexibility according to individual needs:

‘Recognising and working with the trainee. Would they prefer having a debrief after two or three patients, rather than at the end of the surgery?’ (P16)

Administration strategies are helpful

Undertaking administration was time-consuming for dyslexic doctors, including task completion, reviewing letters, processing results, and reviewing and signing prescriptions:

‘Documents are my worst enemy, especially with the bloods and tasks. I find that very overwhelming.’ (P6)

Coming in earlier or leaving later was common: ‘Because I came in early, it gave me extra time and space to look through letters slowly and methodically, equally prescriptions as well’ (P10).

However, other measures included increased scheduled time to undertake administration, and/or a reduced overall number of administrative items, although this raised issues of fairness:

‘Other trainees get 10 letters per session. I said, let’s try 5 letters instead. He had less administrative tasks to do. But I definitely feel that’s an issue.’ (P24)

Longer documents were particularly onerous and printing them for annotation was helpful. A further strategy was using the task function to forward tasks to colleagues, and/or to set personal reminders: ‘I just end up with a very big inbox full of stuff to work through. It’s the only way I'm going to remember to do it later’ (P3).

Minimising interruptions was also important: ‘Having a focused timeframe where you're not going to be interrupted, to sit and go through things, is really helpful’ (P5).

Adaptive technologies are helpful

One adaptive technology was modified headsets that removed ‘distractions’ (P3). Further technologies including adapted keyboards, speech recognition software, and dictaphones to reduce typing burden. Nonetheless, there were challenges:

‘They find using dictaphones really difficult because they've still got to formulate what they're saying. They find it easier to just type it.’ (P15)

Further hardware adaptations included the use of two screens, filters, and modified settings (lighting, colouring, and magnification):

‘So one thing that was suggested was having two screens. And then my efficiency went through the roof.’ (P4)

Software technologies included electronic record spellchecker and predictive text. ‘Having a personalised IT setup that works for that individual’ (P20) was important.

Artificial intelligence for drafting and writing patient notes and referral letters was another measure. However, there were concerns about confidentiality, legal implications, and cost:

‘So you can use ChatGPT, you speak and it will transcribe for you. But obviously, you've got to be very careful not to have patient identifiable information.’ (P10)

Participants also used templates or cheat-sheets that could be pasted into notes:

‘I use templates as much as possible. For children under five, an HRT [hormone replacement therapy] one, baby check template.’ (P3)

Team support is important

Dyslexic doctors often struggled to integrate with the GP team as they were ‘always catching up’ (P8) and because ‘the job is exceptionally isolating. You're on your own for 10 plus hours a day’ (P6).

Nonetheless, participants did report supportive colleagues and peers that helped navigate through clinics, portfolio, and examinations. In particular, buddy groups and allyships within training and GP networks were beneficial.

Educators emphasised the importance of informing wider practice staff: ‘Remember the wider team, because educators might be involved with supervision, but they might not be formulating the timetable’ (P16).

Prescribing strategies are helpful

Prescribing was challenging, with difficulties around drug name similarities and spelling. Strategies included concentration and double-checking:

‘I'm over cautious. I'll always check the BNF [British National Formulary], check it on EMIS. I don't want to make a mistake because of dyslexia.’ (P8)

Numerical difficulties included number recall and calculations. Taking time, using a calculator, and breaking information into chunks (‘chunking’) were useful.

Some participants found electronic prescribing helpful, such as predictive text: ‘If you put the first three letters in, it comes up with suggestions. But the problem is if I don't get the first three letters right, like the one that gets me is flucloxacillin’ (P2).

Another strategy was using electronic drug alerts for interactions, in addition to speaking with colleagues (for example, pharmacist) for complex prescribing.

Accessible resources can be helpful

Clinical (for example, National Institute for Health and Care Excellence [NICE]) and training resources (for example, RCGP, deanery) were helpful. Nonetheless, some were less accessible:

‘If you had dyslexia, trying to understand the information about study leave would be really difficult.’ (P17)

Resources from third-sector organisations were generic and ‘not really what we have, which is an apprenticeship-type environment’ (P24).

Therefore, participants felt that a specific ‘toolkit’ (P23) for GP residents and educators would be useful to ‘help make improvements to identify and support trainees that do have dyslexia’ (P23).

Participants specified useful content of a toolkit: dyslexia recognition; referral pathways; adaptive strategies for workplace and assessments; and experiences following completion of training. Furthermore, it should be electronic, interactive, and contain stories regarding dyslexic GPs who had completed training. Nonetheless, participants emphasised that toolkits must be used flexibly: ‘So having that ability to see what other people do and the freedom to mix and match’ (P11).